Psychosocial predictors of self reported fatigue.pdf

Psychosocial predictors of self-reported fatigue in patients with moderate to severe irritable bowel syndrome Jeffrey M. Lackner a, * , Gregory D. Gudleski a , Jennifer DiMuro a , Laurie Keefer b , Darren M. Brenner b a Department of Medicine, University at Buffalo School of Medicine, SUNY, ECMC, 462 Grider Street, Buffalo, NY 14215, United States b Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States a r t i c l e i n f o Article
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  Psychosocial predictors of self-reported fatigue in patientswith moderate to severe irritable bowel syndrome  Jeffrey M. Lackner a , * , Gregory D. Gudleski a , Jennifer DiMuro a , Laurie Keefer b ,Darren M. Brenner b a Department of Medicine, University at Buffalo School of Medicine, SUNY, ECMC, 462 Grider Street, Buffalo, NY 14215, United States b Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States a r t i c l e i n f o  Article history: Received 26 October 2012Received in revised form28 February 2013Accepted 1 March 2013 Keywords: StressAttentionRestorative environmentsAnxiety sensitivityComorbidityDepressionQuality of life a b s t r a c t The objective of this study was to assess the level, impact, and predictors of fatigue in patients withmoderate to severe irritable bowel syndrome (IBS). One hundred seventy  󿬁 ve patients meeting Rome IIIcriteria for IBS completed a variety of measures including the vitality scale of the SF-12, IBS-SymptomSeverity Scale, IBS-QOL, Brief Symptom Inventory-18, Screening for Somatoform Symptoms (SOMS-7),and a semi structured clinical interview (IBS-PRO) as part of a pretreatment evaluation of an NIH fundedclinical trial of cognitive behavior therapy for IBS. Fatigue was the third most common somaticcomplaint, reported by 61% of the patients. Levels of fatigue were associated with both somatic (moresevere IBS symptoms, greater number of unexplained medical symptoms), behavioral (frequency of restorative experiences) and psychological (e.g., trait anxiety, depression) outcomes after holding con-stant confounding variables. The  󿬁 nal model in multiple regression analyses accounted for 41.6% of thevariance in self-reported fatigue scores with signi 󿬁 cant predictors including anxiety sensitivity,perceived stress, IBS symptom severity, restorative activities and depression. The clinical implications of data as they relate to both IBS and CBT in general are discussed in the context of attention restorationtheory.   2013 Elsevier Ltd. All rights reserved. Introduction Irritable bowel syndrome (IBS) is a chronic gastrointestinal (GI)disorder characterized by recurrent abdominal pain and boweldisturbance (diarrhea and/or constipation) without obvious struc-tural abnormalities, detected through endoscopy or X ray (Mayer,2008). Lacking a biomarker that reliably corresponds to GI symp-toms,IBSisbestunderstoodasafunctionalillness(i.e.,theproblemis in the way the intestinal tract functions) whose onset, trajectoryand impact are in 󿬂 uenced by psychological, physiological, andenvironmental factors (Tanaka, Kanazawa, Fukudo, & Drossman,2011). The interplay of these factors has the potential to disruptbrain e gut interactions and gives expression to GI symptoms. It isbelieved that the effect of psychosocial factors is strongest inseverely affected IBS patients (Lackner, Gudleski, et al., 2012). Withaworldwideprevalenceof10 e 15%(Lovell&Ford,2012),IBSismorecommon than diabetes, asthma, heart disease, or hypertension(Adams & Benson, 1990). Not surprisingly, IBS is one of the mostcommon diseases seen in primary care and specialty GI practices(Mayer, 2008). Because IBS symptoms are painful, emotionallybothersome, intrusive and mimic symptoms of organic GI diseases,IBS results in signi 󿬁 cant direct (e.g., use of healthcare-related ser-vices such as physician visits, diagnostic tests, and prescription orover the- counter medication) and indirect (work absenteeism,diminishedqualityoflife)coststopatients,thehealthcareindustryand employers (Spiegel, 2013).Compounding the social and economic costs of IBS are the highrates of co-occurring medical problems. A large comorbidity studyof patients with IBS, in 󿬂 ammatory bowel disease and healthy con-trolsdemonstratedthatIBSpatientshadamedianoddsratioof1.93of having a symptom-based non-gastrointestinal somatic diagnosis(Whitehead et al., 2007). Indeed, the biggest driver of health  Abbreviations:  SF-36, Short Form-36; SF-12, Short Form-12; IBS PRO, IrritableBowel Syndrome Patient Reported Outcome; IBS-SSS, Irritable Bowel SyndromeSymptom Severity Scale; IBS-QOL, Irritable Bowel Syndrome Quality of Life; PSS,Perceived Stress Scale; PEAT, Pittsburgh Enjoyable Activities Test; NIS, NegativeInteractions Scale; SOMS, Screening for Somatoform Symptoms; DSM-IV, Diag-nostic and Statistical Manual of Mental Disorders  e  IV; STAI, State-Trait AnxietyInventory; ASI, Anxiety Sensitivity Inventory; BSI-Depression Scale, Brief SymptomInventory-Depression Scale; ART, Attention Restoration Theory; AS, AnxietySensitivity; IBS, Irritable Bowel Syndrome; GI, Gastrointestinal; ICD-10, Interna-tional Classi 󿬁 cation of Diseases-10; GERD, Gastroesophageal Re 󿬂 ux Disease. *  Corresponding author. Tel.:  þ 1 716 898 5671; fax:  þ 1 716 898 3040. E-mail address: (J.M. Lackner). Contents lists available at SciVerse ScienceDirect Behaviour Research and Therapy journal homepage: 0005-7967/$  e  see front matter    2013 Elsevier Ltd. All rights reserved. Behaviour Research and Therapy 51 (2013) 323 e 331  care costs of IBS patients are non-GI symptoms (Levy et al., 2001).A common physical symptom is fatigue (Simren, Abrahamsson,Svedlund, & Bjornsson, 2001). Fatigue can be conceptualized(Grandjean, 1968) along a continuum from extreme tiredness,exhaustion, or a need to rest to high energy, strength, vitality, andenthusiasm (Grandjean, 1968). Fatigue differs from normal tired-ness in that it is neither relieved by rest or sleep nor does it corre-spond to one ’ s level of exertion. Previous research has identi 󿬁 edfatigue and loss of energyas important health problems inpatientswith IBS (Gralnek, Hays, Kilbourne, Naliboff, & Mayer, 2000; Labus, Mayer,Chang,Bolus,&Naliboff,2007;Mayer,2000).Inalargegroup ofIBSpatients,fatiguepredictedbothphysicalandmentalaspectsof qualityoflifeasmeasuredbytheSF36HealthSurvey(Spiegeletal.,2004). That said, little is known about the different dimensions of fatigue (e.g., frequency, impact) or how they relate to other aspectsof IBS such as GI symptoms, mental well-being, IBS speci 󿬁 c qualityof life, interpersonal relationships (e.g., negative interactions withothers), cognitive style (e.g., anxiety sensitivity, catastrophizing) oractivity level. Nor is it clear what other factors predict excessivefatigue in IBS patients. Understanding the predictors of a clinicallymeaningful problem like fatigue is important because this infor-mation may help promote the development of more effectivebehavioral symptom self-management strategies that, in theabsenceofasatisfactorymedicaltreatment,couldrelievethedaytoday burden of IBS.A more complete understanding of the nature and clinical sig-ni 󿬁 canceofa “ nonspeci 󿬁 c ” symptomlikefatiguerequiresclarifyingwhether it is a separate and distinct symptom or secondary to anynumber of medical or mental disorders that are comorbid with IBS and  characterized by fatigue/loss of energy. It possible that com-plaints of fatigue are simply due to co-existing depression whichaffects approximately 20% of IBS patients (Blanchard, 2000). If so,then the magnitude of the observed relationship between fatigueand depression (Asare et al., 2012) may re 󿬂 ect the degree of sta-tistical overlap (i.e., multicollinearity) between the items used tomeasure both constructs and not a clinically meaningful phenom-enon. Multicollinearity is an important but often overlookedmethodological issue that arises when two (or more) related vari-ables provide redundant information; that is, constructs aredescribed as conceptually different but tap the same underlyingvariable. A similar problem applies to the relationship betweenfatigue and somatization. It is unknown whether unexplained fa-tigue is part of a set of medically benign symptoms that are re-ported by somatizing patients who express emotional distress inthe form of physical complaints. The aims of this study were toexaminetheleveloffatigueperceivedbymoreseverelyaffectedIBSpatientsandtoexplorethepotentialfactorsin 󿬂 uencingfatigueandits relationship to other aspects of IBS. Method Participants Participants included 176 consecutively evaluated IBS patientsrecruited primarily through local media coverage and communityadvertising and referral by local physicians to a tertiary care centerat 2 academic medical centers. To qualify, participants must havemet Rome III IBS diagnostic criteria (Drossman, Corazziari, Talley,Thompson, & Whitehead, 2000) without organic gastrointestinaldisease (e.g., IBD, colon cancer, etc) as determined by a board-certi 󿬁 ed study gastroenterologist. Rome criteria de 󿬁 ne IBS asrecurrent abdominal pain or discomfort at least 3 days per monthover the last 3 months that is associated with at least 2 of thefollowing: 1) improvement with defecation, 2) onset associatedwith a change in stoolform, or 3) onset associated with a change inthe frequency of stool (Drossman, Corazziari, Talley, Thompson, &Whitehead, 2006). Because this study was conducted as part of a clinical trial for moderate to severely affected patients with IBS(Lackner, Keefer, et al., 2012), participants must have also reportedIBS symptoms of at least moderate intensity, symptoms occurringat least twice weekly for 6 months  and  causing life interference.Institutional review board approval and written, signed consentwereobtainedbeforethestudybegan.Thisstudywascompletedinfull compliance with the Declaration of Helsinki. Procedure After a brief telephone interview to determine whether partic-ipantswerelikelytomeetbasicinclusioncriteria,participantswerescheduled for a medical examination to con 󿬁 rm IBS diagnosis(Drossman, Corazziari, et al., 2000; Longstreth et al., 2006) and psychometrictesting,whichforthepurposesof thisstudyincludedthe test battery described below.  Assessment measuresFatigue Theprimaryunitofanalysisforstatisticalanalyseswasbasedonthe vitality scale of the SF-12 Health Survey (Ware, Kosinski, &Keller, 1996). The SF-12 contains 12 items from the SF-36 HealthSurvey, a generic measure of quality of life that measures eightdomains of health: physical functioning, role limitations due tophysical health, bodily pain, general health perceptions, vitality,social functioning, role limitations due to emotional problems andmental health. The SF-12 vitality scale requires respondents toindicatehowmuchof thetimeduringthepast fourweekstheyhada lotof energy. Possible responses ranged from1 (all of the time) to6 (none of the time) with lower score indicating higher vitality(greater energy/lower fatigue).Inadditiontomeasuringfatigueintensity,wewereinterestedindescribing the clinical signi 󿬁 canceof reported self-reportedfatigueas measured by the Patient Reported Outcomes Interview for theFunctionalGastrointestinalDisorders:IBSModule(IBS-PRO,Keefer,Lackner, & Brenner, 2009). The IBS-PRO is a clinician administeredstructured interview that assesses the frequency and impact of individual IBS symptoms as speci 󿬁 ed by Rome criteria. For eachitem,standardizedquestionsandprobesareprovided.Themeasurecontains separate 0 e 4 frequency and impact scales. Consistentwith Rome criteria, the IBS PRO assesses symptoms over the past 3months. The structure and format of the IBS-PRO is based on othersemi structured instruments (Blake et al.,1995) that gauges clinicalsigni 󿬁 cancewithreferencetospeci 󿬁 cdimensionsthatareregardedas important to describing symptom severity (i.e., frequency, sub- jective distress, functional impairment). Frequency ratings arebased on the percent of time the symptom has occurred over thepast 3 months from the patient ’ s perspective. Frequency percent-ages correspond one of   󿬁 ve adjectival descriptors (e.g., 25% corre-spond with the  “ sometimes ”  descriptor) de 󿬁 ned by previous IBSresearchers (Drossman, Corazziari, Delvaux, et al., 2006). A secondrating is made for the impact of symptom based on the patient ’ slevel of distress and/or impairment due to symptoms. Ratings aremade on a scale with brief descriptors attached to each of the  󿬁 vescale values. Symptoms can thus have individual scales rangingfrom 0-0,1-1,1-2, 2-1, 2-2,1-3, up to 4-4, with the  󿬁 rst digit of thenumber pair representing the frequency and the second digit rep-resenting the impact of symptom. A symptom registers as clinicallymeaningful if it meets the  “ rule of three ”  e  that is, the sum of frequencyandimpactyieldsascoreofthreeorgreater.IBSPROdatawere used for descriptive purposes and not included in analyses(e.g., correlations, regression analyses).  J.M. Lackner et al. / Behaviour Research and Therapy 51 (2013) 323 e  331 324  IBS symptom severity TheIrritableBowelSyndromeSymptomSeverityScale(IBS-SSS;Francis, Morris, & Whorwell, 1997) is a 5-item instrument used tomeasure severity of abdominal pain, frequency of abdominal pain,severity of abdominal distension, dissatisfactionwith bowel habits,and interference with quality of life, each on a 100-point scale. Forfour of the items, the scales are represented as continuous lineswith endpoints 0% and 100%, with different descriptors at theendpoints and adverb quali 󿬁 ers (e.g.,  “ not very, ” “ quite ” ) strategi-cally placed along the line. Respondents mark a point on the linebetween the two endpoints re 󿬂 ecting the extremity of their judg-ment. The proportional distance from zero is the score assigned forthat scale (hence scores rangefrom0to100). The endpointsfor theseverity items are  “ no pain ”  and  “ very severe, ”  for satisfaction, theendpoints are  “ not at all satis 󿬁 ed ”  and  “ very satis 󿬁 ed, ”  and forinterference they are  “ not at all interferes ”  to  “ completely in-terferes. ”  A  󿬁 nal item asks the number of days out of 10 the patientexperiences abdominal pain and the answer is multiplied by 10 tocreate a 0 to 100 metric. The items are summed and thus the totalscore can range from 0 to 500. Quality of life The IBS-QOL (Drossman, Patrick, et al., 2000) is a 34-item mea-sure constructed speci 󿬁 cally to assess the subjective well-being of patients with IBS. Each item is scored on a  󿬁 ve-point scale (1 ¼ notat all, 5  ¼  a great deal) that represents one of eight dimensions(dysphoria, interference with activity, body image, health worry,food avoidance, social reaction, sexual dysfunction, and relation-ships).ItemsarescoredtoderiveanoveralltotalscoreofIBSrelatedquality of life. To facilitate score interpretation, the summed totalscore is transformed to a zero to 100 scale ranging from zero (poorquality of life) to 100 (maximum quality of life). IBS-QOL has goodreliability (Cronbach ’ s alpha  ¼  .95), convergent validity andconstructvalidity(Drossman,Patrick,etal.,2000)andsensitivitytochange following CBT of different  “ dosages ”  (Lackner et al., 2008). Perceived Stress Scale (PSS) The PSSmeasuresthe degree towhich situations inone ’ s life areappraisedasstressful(Cohen,Kamarck,&Mermelstein,1983)).The4item version of the PSS (Cohen & Williamson, 1988) was used. Itsitemsaredesignedtotapthedegreetowhichrespondents 󿬁 ndtheirlives uncontrollable, unpredictable and overloading. These threefactorshavebeenconsistentlyfoundtobecentralcomponentsofthestress experience. Item are rated on a 5 point Likert scale rangingfrom 0 (never) to 4. The PSS-4 shows adequate reliability with aCronbach ’ s alpha of .85 as well as acceptable correlations withmeasures of conceptually congruent constructs (Cohen et al.,1983).  Abdominal pain Abdominal pain intensity over the previous 7 days wasmeasured with an 11-point numerical rating scale (PI-NRS), where0  ¼  no pain and 10  ¼  worst possible pain (Turk et al., 2006). Pa-tients circled the number from 0 to 11 that best described theiraverage abdominal pain over the past 7 days. This pain measure iswidely used and recommended instudies of patients withIBS(M. P. Jensen, Karoly, & Braver, 1986). Pleasant activities The Pittsburgh Enjoyable Activities Test scale (PEAT) (Pressmanet al., 2009) is a 10 item scale that assesses the frequency of involvement in a spectrum of leisure activities associated withfeelings of renewed energy, concentration and mental clarity. Theten items include: spending quiet time alone; spending time un-winding; visiting others; eating with others; doing fun things withothers; club, fellowship and religious group participation;vacationing; communing with nature; sports; and hobbies. Theseactivitiesarebelievedtoenhancewell-beingbyactingasbreathers,restorersandstressbuffers.InstructionsforthePEATwere: “ Weareinterested in how often in the last month you were able to spendtime in activities that you enjoyed. Overthe past month, howoftenhave you been able to spend time doing the following? ”  Responseoptionsrangedfrom “ Never ” (0point)to “ EveryDay ” (4points)and “ Not Applicable/Do Not Enjoy ”  (0 point). The PEAT was scored asthe sum of all items (maximum ¼ 40). Depression Depressive symptoms were measured using the depressionscale of the 18 item version of the Brief Symptom Inventory(Derogatis, 2000). The scale includes 5 items rated on a 5 pointscale (0- not at all, 1, a little bit, 3  ¼  quite a bit, 4  ¼  extremely) tore 󿬂 ect respondents ’  distress about depressive symptoms (e.g.,feeling lonely, blue, worthless, hopeless). The BSI has been usedextensively in IBS research (Dorn et al., 2007). Internal consistency,test e retestreliability,andvalidityoftheBSI-18arewellestablished(Derogatis, 2000). Somatization Somatization was measured using the Screening for Somato-formSymptoms-7(SOMS-7,Rief&Hiller,2003).TheSOMSincludesatotalof53physicalsymptoms,drawnfromtheDSM-IV(AmericanPsychiatricAssociation,1994)andtheInternationalClassi 󿬁 cationof Diseases (ICD-10) de 󿬁 nitions for somatization disorder and soma-toform autonomic dysfunction. Subjects are instructed to reportonly complaints for which physicians have found no currentlyphysical pathological cause. Respondents are asked (Rief & Hiller,2003) to report the symptoms that have been present during thepast 7 days. The total number of endorsed symptoms yields a so-matization symptom count which has been found to discriminatepatientswithsomatoformdisordersfromthosewithotherformsof mental disorders. To avoid collinearity problems, we excluded thefatigue item when calculating the somatization. The SOMS-7 hasdemonstrated high internal consistency (Cronbach ’ s alpha  ¼  .92),reasonabletest-retestreliability( r  ¼ .76)andhighassociationswitha number of somatoform disorders (Rief & Hiller, 2003).  Anxiety Trait anxiety was measuredusing the abbreviatedTraitsubscaleof the STAI (Spielberger,1995). In responding to the 10 items of theT-Anxiety scale, subjects indicate how they generally feel by ratingthe frequency of their feelings of anxiety on a 4-point scale rangingfrom1(almostnever)to4(almostalways).Awidebodyofresearchsupports the construct validity, test e retest reliability, and reli-ability of the STAI (Spielberger, 1989). Interpersonal functioning  Interpersonal functioning was measured with the Negative In-teractions Scale (NIS). The NIS assesses social encounters and in-teractions that are characterized by con 󿬂 ict, excessive demandsand/or criticism (30, 31). Our version of the NIS includes 5 itemsthatassessthefrequency(rangingfrom1 ¼ neverto4 ¼ veryoften)of negative social exchanges with a spouse, family members,friends, neighbors, in-laws. The scale includes four items from thesrcinal 4-tem scale developed and validated by Krause and oneadditional item drawn from Schuster, Kessler, and Aseltine (1990)( “ How often do they let you down when you are counting onthem? ” )andusedintheMIDMAC(MacArthurFoundationResearchNetwork on Successful Midlife Development). Participants wereasked  “ In the past month, how often have others . ”  about ex-changes such as  “ . made too many demands on you? ” ,  “ . beencriticalofyou? ” , “ . priedintoyouraffairs? ” , “ . takenadvantageof   J.M. Lackner et al. / Behaviour Research and Therapy 51 (2013) 323 e  331  325  you? ”  and  “ . let you down when you were counting on them? ” High scores suggest that respondents engage in negative in-teractions more frequently. The  󿬁 ve item NIS is part of the assess-ment battery for social/environmental burdens of the PittsburghMind Body Center, a joint research project of the University of Pittsburgh and Carnegie Mellon University. Pain catastrophizing  The two item version of the catastrophizing subscale of theCoping Strategies Questionnaire ( Jensen, Keefe, Lefebvre, Romano,& Turner, 2003) asks patients to rate the frequency with whichthey engage in thoughts that index catastrophizing during painepisodes (e.g.,  ‘‘ When I am in pain, I feel I can ’ t stand it anymore).Respondents rate each itemusing a scale ranging from 0 (neverdo)to 7 (always do).  Anxiety Sensitivity Inventory The ASI (Peterson & Reiss, 1993) is a self-report measure thatre 󿬂 ects fear of anxiety (e.g.,  ‘‘ It scares me when I am anxious ’’ ),arousal related bodily sensations ( ‘‘ It scares me when my heartbeats rapidly ’’ ) and their consequences (e.g.,  ‘‘ When I notice myheart is beating rapidly, I worry that I might have a heart attack ’’ ).Each of the 16items of the ASI is ratedon a six point scale (0 ¼ verylittle, 5  ¼  very much). In addition to a total score, the ASI yieldsthree empirically derived subscales relating to fear of publiclyobservable anxiety reactions (e.g., fear of trembling arising frombeliefsthattremblingwillbenegativelyevaluated),fearsofsomaticsymptoms (e.g., It scares me when my heart beats rapidly ” , andfears of cognitive dyscontrol (fear of concentration dif  󿬁 cultiesarising from beliefs that such dif  󿬁 culties have catastrophic conse-quences). The ASI has demonstrated sound psychometric proper-tiesinbothclinicalandnonclinicalsamples,includinghighinternalconsistency ( a  .80 to .90; (Peterson & Reiss, 1993; Taylor, 1999; Telch, Shermis, & Lucas, 1989). Medical comorbidity Because poor physical health may impact energy/fatigue, non-psychiatric medical comorbidity was assessed using a modi 󿬁 edversion of the survey used in the National Health Interview Survey(NHIS) to record the recency of commonly occurring chronicconditions believed to be associated with substantial quality of lifeimpairment (Schoenborn, Adams, & Schiller, 2003). We haveadapted the NHIS checklist to characterize physical comorbidity of IBS patients in three NIH funded clinical trials (Lackner et al.,2006). The current version (Lackner, Brenner, & Keefer, 2009) covers 112 medical conditions organized around 12 body systems(musculoskeletal, digestive, kidney/genitourinary, endocrine, res-piratory, circulatory, cardiovascular, oral, CNS, dermatological,Ear Nose, Throat [ENT], cancer). Respondents were asked whethera doctor had ever diagnosed them with a condition and, if so,whether the condition was present in the past 3 months.Persons were counted as current cases if the diagnosed conditionwas reported as present in the last 3 months. The checklist wasconstructed to capture information about the most commoncomorbidities in the general population, those believed to occurfrequently in IBS patients, those regarded as most important to IBSpatients and those regarded as most important in existing co-morbidity measures (Charlson, Pompei, Ales, & MacKenzie, 1987).A total comorbidity score was based on the number of medicalcomorbidities a patient reported as present over the previous 3months. Evidence for the discriminant and convergent validitycomes from correlation analyses showing that number of medicalcomorbidities is associated with physical (  .41) but not mentalaspect of quality of life as assessed with the SF 36 Healthy Survey(Lackner, Ma, et al., in press). Data analyses plan Data analyses were carried out in three steps. The  󿬁 rst step wasto characterize the sample using means, standard deviations orpercentages. At the second step, we conducted partial correlationsto describe the relationship between each clinical variable afterholding constant potentially confounding variables including age,education, income, marital status, IBS subtype and duration of symptoms. Because correlations do not account for overlap amongvariables, the third step involved multiple regression analyses todetermine the proportion of variance in fatigue accounted for by acombination of demographic, psychosocial, and somatic variables. Results Characteristics of the sample Table 1 displays the demographic and clinical characteristics of the sample. The sample was predominately young, educated, fe-male and chronically ill (average duration of IBS symptoms ¼ 16.5years). The mean total score on the IBS-SSS for the samplefalls in the high moderate range of IBS symptom severity  Table 1 Demographic and clinical characteristics ( N  ¼ 176). M   (SD)  N   (%)Age 41.0 (15.0)Gender (% female) 138 (78.4%)Race (% white) 160 (90.9%) Education High school or less 36 (20.6%)College degree 75 (42.9%)Post-college degree 51 (29.1%)Other 13 (7.4%) Income < 15,000 14 (8.0%)15,001 e 30,000 21 (12.0%)30,001 e 50,000 35 (20.0%)50,000 e 75,000 30 (17.1%)75,001 e 100,000 11 (6.3%)100,001 e 150,000 15 (8.6%) > 150,000 20 (11.4%)Don ’ t know/Not sure 9 (5.1%)Prefer not to answer 20 (11.4%)Duration of sxs (years) 16.5 (14.3) IBS Subtype IBS-Constipation 46 (26.1%)IBS-Diarrhea 76 (43.2%)IBS-Alternating 54 (30.7%)IBS-SSS 284.7 (76.3)IBS-QOL 56.0 (19.3)Abdominal pain 5.0 (2.0)# Medical comorbidities 4.3 (4.6)PEAT 31.7 (6.3)BSI-Depression 4.5 (4.8)SOMS-7 7.7 (5.7)STAI-Trait anxiety 20.7 (6.4)NIS 10.3 (3.2)Catastrophizing 2.6 (1.7)PSS 7.1 (3.4)ASI 24.9 (12.0)Physical concerns 14.7 (8.0)Psychological concerns 7.3 (5.9)Social concerns 7.2 (2.4)Fatigue 4.1 (1.2) Note : Duration sxs  ¼  Duration of IBS symptoms; IBS-SSS  ¼  IBS Symptom SeverityScale; IBS-QOL   ¼  IBS Quality of Life; # Medical Comorbidity  ¼  Number of MedicalComorbidities; PEAT ¼ Pittsburgh Enjoyable Activities Test; BSI-Depression ¼ Brief Symptom Inventory-Depression Scale; SOMS7  ¼  Screening for SomatoformSymptoms-7; STAI-Trait  ¼  State-Trait Anxiety Inventory e Trait Scale;NIS  ¼  Negative Interaction Scale; Catastrophizing  ¼  Pain Catastrophizing;PSS ¼ Perceived Stress Scale; ASI ¼ Anxiety Sensitivity Index.  J.M. Lackner et al. / Behaviour Research and Therapy 51 (2013) 323 e  331 326
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